Objective To determine if the addition of nurse case managers (NCMs) trained in motivational interviewing (MI) to usual care would result in improved outcomes in high risk type 2 diabetes patients. Methods A 2-year randomized controlled pragmatic trial randomized 545 patients to usual care control (n=313) or those who received the intervention (n= 232) with additional practice embedded NCM care, including MI-guided behavior change counseling. NCMs received intensive MI training with ongoing fidelity assessment. Results Systolic BP was better in the intervention group (131±15.9 vs. 135±18.2, p < 0.05). HbA1c, LDL, and diastolic BP improved in both groups: HbA1c (control group 9.1% to 8.0%, intervention group 8.8% to 7.8%), LDL (control group 127 to 100 mg/dL, intervention group 128 to 102 mg/dL), diastolic BP (control group 78 to 74 mm Hg, intervention group 80 to 74 mm Hg). Depression symptom scores were better in the intervention group. The reduction in diabetes-related distress approached statistical significance. Conclusions NCMs and MI improved systolic BP and complications screening. The large decrease in HbA1C and LDL in the control group may have obscured any further intervention effect. Although nurses prompted providers for medication titration, strategies to reduce provider clinical inertia might also be needed. Significant findings of the study In patients with type 2 diabetes, an intervention with nurse case management and motivational interviewing improves systolic blood pressure, depression, and screening for complications. What this study adds First study to look at the benefit of the addition of motivational interviewing to nurse case management in the care of the high-risk adult with type 2 diabetes. Particular attention was given to ensuring fidelity to the motivational interviewing approach.

Social media can augment learning opportunities within humanities curriculum in medical schools, and help students acquire tools and skill-sets for problem solving, networking, and collaboration. Command of technologies will be increasingly important to the practice of medicine in the twenty-first century.

This qualitative study was conducted to examine the decision-making process and its immediate consequences for family members who placed an elderly loved one in a long-term care facility. To explore issues related to the placement process, in-depth interviews were conducted with 7 individuals who had recently (6 weeks or less) placed an older relative. Content analyses of the interviews were conducted, and several common themes related to the decision-making process and outcomes emerged. Most of the subjects had provided personal care for their elderly relative, so placing their loved one in a nursing home often conflicted with their view of themselves as an ideal caregiver. During the process of making the decision, although family members were given advice and suggestions by health care professionals, this input was viewed as inadequate or even detrimental. Ultimately, subjects described making the decision to place an elderly relative in a long-term care facility as a singular process involving "I" rather than "we." The positive and negative role of friends emerged as an important influence during and after the placement process. The informal validation of the decision to place by peers was the one interaction that family members identified as helpful during this process.

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Admission to a nursing home is a major life event for both older people and family carers. Despite a policy of community care in both the UK and the US, entry to nursing homes will be an increasingly common event. Family carers are often the key decision makers but little is known about their experience of placement, especially adjustment after the event. Antagonistic relationships can often develop between staff and relatives, as the former seek to take over care and the latter to develop new roles. There is a need to create a partnership between staff and family so that the care of the older person is improved and the carers' need to remain involved is acknowledged.

Background Advance care planning (ACP) is an under-utilized process that involves thinking about what kind of life-prolonging medical care one would want should the need arise, identifying a spokesperson, and then communicating these wishes. Objective To better understand what influences individuals to engage in ACP. Design Three focus groups using semi-structured interactive interviews were conducted with 23 older individuals from three diverse populations in central Pennsylvania. Results Four categories of influences for engaging in ACP were identified: 1) Concern for Self; 2) Concern for Others; 3) Expectations About the Impact of Advance Care Planning; and 4) Anecdotes, Stories, & Experiences. Conclusions The motivations for undertaking ACP that we have identified offer healthcare providers insight into effective strategies for facilitating the process of ACP with their patients.

This paper considers placing a relative in a nursing home from a carer's perspective. A largely structured, interviewer-administered, questionnaire survey was conducted with 48 carers in the United Kingdom and 54 carers in the United States of America. While the data highlight differences between the two countries, shared experiences emerge which suggest that carers often have to make difficult decisions without adequate support. Implications for practice are considered. The need to develop more robust support mechanisms is stressed.

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